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5Long-term outcome with interstitial brachytherapyin the management of patients with early-stage breast cancer treated with breast-conserving therapy
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LONG-TERM OUTCOME WITH INTERSTITIAL BRACHYTHERAPYIN THE M A N A G E M E N T OF P A T I E N T S W I T H E A R L Y - S T A G E B R E A S T C A N C E R T R E A T E D W I T H B R E A S T - C O N S E R V I N G THERAPY.
Quality Assurance with computerised Database in breast consen'ative brach~..lherap.~ Iridium ~9" boost.
Pera J, L6pez Y, M o r e n o P, G u t i e r r e z C, Pr~eto L', Gil M*, Lloveras B°, Guedea F. Radiation Oncology Department. " Breast Functional Unit. Institut Catala d'Oncologia. C.S.U.Bellvitge. 08907 L'Hospitalet (Barcelona). Spain.
Burette R / : , D e t r o u x L. ~,ltemeleers C?,Vandeville J/, \:anderick J" VanDycke M. ~, Vaaderlinck: A. 'CI.St Jean - Radiotherapy Dpt - IMEC Centre Cogniaux: 114 rue du Marais - 1000 BRUSSELS DC 1180 - rue ECavel132
Eh/r~se: We reviewed our i n s t i t u t i o n ' s e x p e r i e n c e with i n t e r s t i t i a l implant boost to d e t e r m i n a t e the l o n g - t e r m impact on local control, survival and cosmetlc results. Methods and Materials: Between 1989 and 1996, 500 patients with Stage I and It breast cancer were m a n a g e d with b r e a s t - c o n s e r v i n g therapy [BCT) at Institut Catal~ d'Oncologia [ICe). All patients were treated with consevative sugery and axillary node dissection. R a d i a t i o n c o n s i s t e d of 50 Gy external b e a m i r r a d i a t i o n to the whole breast followed by a boost to the tumor bed to at lease 60 Gy with brachytherapy. All the implants were performed with 192-Ir. The mean dose with brachytherapy was 17 Gy. The mean dose rate was 66 cGy/h. The m e a n treated volume was 51 x 54 × 27 mm3. Most of the implants were p e r f o r m e d with rigid neddles, although in 2% we used plastic tubes. The mean number of sources was 8. L o n g - t e r m local control, survival and cosmetic outcome were assesed. ~sulta: With a m e d i a n follow-up of 42 months (max.ll9, min 13 months), 2% of the patients have recurred in [he I r e a t ~ d breast and the s~lrviv~l al 5 years is q ~ . Greater than 80% el p,ltleltt:~ obtainl:d .1 good u~ excellent cosmetic result. Only 1.4% of the patients d e v e l o p e d an infectious mastitis. Conclusions: We conclude that patients with Stage I and II breast cancer can be m a n a g e d with b r a c h t h e r a p y as a boost technique using LOB interstltial brachytherapy. This technique is well tolerated. L o n g - t e r m control and cosmetic outcome are e x c e l l e n t and similar to the series reported in the literature.
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From 9/84 to 9/94, 514 patients with T I - 2 N0-1 M breasts cancers have been treated by conservative surgery with axillary nodes dissection with external therapy and Iridium'~'2brachytherapy as a boost. Chemotherapy was delivered (CMF 6 cures) for node positive premenopausal and/or undiffereuciated carcinomas. Hormonal therapy was associated with O E positive receptors. All patients had simulation and TPS calculation (Plato* and Isis*) with four different techniques following Paris-System rules in relationship with different type of needles, with or without source projectors and LDR-MDR management(Baden-Baden,Venise and York GEC-ESTRO ; Den Haag Nucletron User's meetings). Physical parameters were regularly and 'patiently' collected in order to compare the reproducibility of the technique and QA for each patient. Templates in triangle with 16~18mm spaced rigid needles were homogeneously used. Length (cm), Activity (mCi), Dose rates (cGy/h), Doses (cGy) and dose r a t e s / m C i (cGy/h/mCi) on 85% reference isodose with standard deviation were matched. QA assurance results show 1,9 to 2,91% SD from 16 mm spaced rigid 15G Nucletron ° needles L D R - M D R remote afterloading to 18mm thin 18G handloading needles. C o n c l u s i o n s : Physical datas collection and QA controled by computerised information database enables the Dpt to: - predict TPS less than 2-3% SD & check abnormal result - enhance TPS/simulatioa QA for various type of errors - increase dose rates without undue technical uncertainties - apply dose delivery for predictive virtual brachytherapy.
8 EXCELLENT 5 AND 10 YEAR RESULTS OF EBRT AND 192 IRIDIUM
BT
1N 644 PATIENTS WITH BREAST CANCER J Hammer,C Track. DH Seewald.JP Zoidl. W Labeck, E Putz. B Grey Departmentof RadiationOntology, BarmherzigeSchwesternHospital,Linz,Austria Introduction: Since 1984 HDR Iridium-192 bracbytherapy(BT) has been used to deliver an interstitial boost to the primary tumour site in conservative breast cancer treatment. The authors present survival data of a prospective treatment method and demonstrate the safe use of lr-192 high dose rate (HDR) implantations. M a t e r i a l a n d m e t h o d s : Up until December 1995 644 patients with 649 tumours have been treated (TI: 432, T2: 217, N+: 180, N-: 469). Treatment method included external beam radiotherapy (EBRT) of 45 to 50 Gy to the breast followed by an interstitial 10 Gy boost. Mean follow up of survivors: 77 months (25 to 158). Results: 5-years actuarial data (10-yr. data in brackets): Overall survival: 89.6 % (75.0 %), local control: 96.5 % (92.0 %), disease free survival: 85.5 % (77.5 %), and disease specific survival: 92.9 % (82.2 %). Local control according T-stage: TI 97.6 % (93.5 %); T2 94.2 % (89.2 %). There were no severe complications, except 1 patient with periostitis and neuralgia. The cosmetic results are very satisfactory. C o n c l u s i o n : The use of a HDR source in boosting the primary tumour site after external beam radiotherapy with a dose of 10 Gy in I fraction is a safe procedure. Our 5-years local relapse (T1 and T2) rate of 3.5 % (10-yr.: 8.0 %) and survival data are very similar to those reported in literature. Therefore we will continue with the described prospective approach.
HDR-Brachytherupy Boost for TI/T2-Breast Cancer-First Results ofu Longtcnn Follow up E.Biber, A.Resch, G. Laagbauer, T.Klcin, C. Fcllner. W. Scitz, R. Pttter University DeparUuent of Radiotherapy and Radiobiology, Vienna
888 patients with breast cancer TIll'2 N0/NI were treated with breast conserving surgery and radiotherapy (EBT and BT) between 1983 and 1992. 421 patients have been reinvestigated in a recent study with the aim to evaluate the influence of treatment on outcome and cosmetic results. 251 pts. underwent quadrantectomy, 165 tmnorectomy all with axilladissection. All pts. received EBT combined with interstitial brachytherapy (IBT).Total dose of EBT was mean 50 Gy (45 to 60 Gy) at the ICRU-point (Cobalt-60 n=219,6 MeV n=202). For HDP,BT with Ir-192 (n=288) the prescribed dose was mean I I Gy ( 10 to 12 Gy), specified to the isodose at 1 cm from the outer needle. Template technique was used in triangular configuration with mean 7 needles (4 to 10 needles) in two planes.A reevaluation was done in 50 cases resulting in the following: on the average mean central dose 17 Gy (15 to 20 Gy), treated volume 85 ccm (50 to 140ecru), TRAK 0.05 cGy at 1 m. A local recurrence ocurred in 18 of 421 cases (4,3%), 4 in the same quadrant. 343/421 pts. survived after a follow-up median 9 y. The cosmetic results were investigated with a specific questionnaire (Lent-score, QuoL) and were estimated as good (2) or excellent ( I ) (score I to 5) by 80"/, of the wo,nen, less favourable by the physicians. Fibrosis, teleangiectasia were scored according to Lent-score (fibrosisgrade 1-23%, G2-19%, G3-2.6%; Telcangieetasia G 1-8.8"/,, G2-4.4%, G3-2.6%). Poor cosmetic results were found in only 3%. The most hnponant parm'nctcrs for COSlncticoulcolne were surgical procedure, treated volu,ne (more than 100 ccm), radiation dose (> 80 Gy), inadequate application technique. In conclusion: ItDR-interstilial B'I" (Ir-192) reveals excellent local control rates and good cosmetic resulls. Dose and volume reduction of HDR-BT has been inlroduccd since 1994.
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LONG-TERM OUTCOME WITH INTERSTITIAL BRACHYTHERAPYIN THE M A N A G E M E N T OF P A T I E N T S W I T H E A R L Y - S T A G E B R E A S T C A N C E R T R E A T E D W I T H B R E A S T - C O N S E R V I N G THERAPY.
Quality Assurance with computerised Database in breast consen'ative brach~..lherap.~ Iridium ~9" boost.
Pera J, L6pez Y, M o r e n o P, G u t i e r r e z C, Pr~eto L', Gil M*, Lloveras B°, Guedea F. Radiation Oncology Department. " Breast Functional Unit. Institut Catala d'Oncologia. C.S.U.Bellvitge. 08907 L'Hospitalet (Barcelona). Spain.
Burette R / : , D e t r o u x L. ~,ltemeleers C?,Vandeville J/, \:anderick J" VanDycke M. ~, Vaaderlinck: A. 'CI.St Jean - Radiotherapy Dpt - IMEC Centre Cogniaux: 114 rue du Marais - 1000 BRUSSELS DC 1180 - rue ECavel132
Eh/r~se: We reviewed our i n s t i t u t i o n ' s e x p e r i e n c e with i n t e r s t i t i a l implant boost to d e t e r m i n a t e the l o n g - t e r m impact on local control, survival and cosmetlc results. Methods and Materials: Between 1989 and 1996, 500 patients with Stage I and It breast cancer were m a n a g e d with b r e a s t - c o n s e r v i n g therapy [BCT) at Institut Catal~ d'Oncologia [ICe). All patients were treated with consevative sugery and axillary node dissection. R a d i a t i o n c o n s i s t e d of 50 Gy external b e a m i r r a d i a t i o n to the whole breast followed by a boost to the tumor bed to at lease 60 Gy with brachytherapy. All the implants were performed with 192-Ir. The mean dose with brachytherapy was 17 Gy. The mean dose rate was 66 cGy/h. The m e a n treated volume was 51 x 54 × 27 mm3. Most of the implants were p e r f o r m e d with rigid neddles, although in 2% we used plastic tubes. The mean number of sources was 8. L o n g - t e r m local control, survival and cosmetic outcome were assesed. ~sulta: With a m e d i a n follow-up of 42 months (max.ll9, min 13 months), 2% of the patients have recurred in [he I r e a t ~ d breast and the s~lrviv~l al 5 years is q ~ . Greater than 80% el p,ltleltt:~ obtainl:d .1 good u~ excellent cosmetic result. Only 1.4% of the patients d e v e l o p e d an infectious mastitis. Conclusions: We conclude that patients with Stage I and II breast cancer can be m a n a g e d with b r a c h t h e r a p y as a boost technique using LOB interstltial brachytherapy. This technique is well tolerated. L o n g - t e r m control and cosmetic outcome are e x c e l l e n t and similar to the series reported in the literature.
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From 9/84 to 9/94, 514 patients with T I - 2 N0-1 M breasts cancers have been treated by conservative surgery with axillary nodes dissection with external therapy and Iridium'~'2brachytherapy as a boost. Chemotherapy was delivered (CMF 6 cures) for node positive premenopausal and/or undiffereuciated carcinomas. Hormonal therapy was associated with O E positive receptors. All patients had simulation and TPS calculation (Plato* and Isis*) with four different techniques following Paris-System rules in relationship with different type of needles, with or without source projectors and LDR-MDR management(Baden-Baden,Venise and York GEC-ESTRO ; Den Haag Nucletron User's meetings). Physical parameters were regularly and 'patiently' collected in order to compare the reproducibility of the technique and QA for each patient. Templates in triangle with 16~18mm spaced rigid needles were homogeneously used. Length (cm), Activity (mCi), Dose rates (cGy/h), Doses (cGy) and dose r a t e s / m C i (cGy/h/mCi) on 85% reference isodose with standard deviation were matched. QA assurance results show 1,9 to 2,91% SD from 16 mm spaced rigid 15G Nucletron ° needles L D R - M D R remote afterloading to 18mm thin 18G handloading needles. C o n c l u s i o n s : Physical datas collection and QA controled by computerised information database enables the Dpt to: - predict TPS less than 2-3% SD & check abnormal result - enhance TPS/simulatioa QA for various type of errors - increase dose rates without undue technical uncertainties - apply dose delivery for predictive virtual brachytherapy.
8 EXCELLENT 5 AND 10 YEAR RESULTS OF EBRT AND 192 IRIDIUM
BT
1N 644 PATIENTS WITH BREAST CANCER J Hammer,C Track. DH Seewald.JP Zoidl. W Labeck, E Putz. B Grey Departmentof RadiationOntology, BarmherzigeSchwesternHospital,Linz,Austria Introduction: Since 1984 HDR Iridium-192 bracbytherapy(BT) has been used to deliver an interstitial boost to the primary tumour site in conservative breast cancer treatment. The authors present survival data of a prospective treatment method and demonstrate the safe use of lr-192 high dose rate (HDR) implantations. M a t e r i a l a n d m e t h o d s : Up until December 1995 644 patients with 649 tumours have been treated (TI: 432, T2: 217, N+: 180, N-: 469). Treatment method included external beam radiotherapy (EBRT) of 45 to 50 Gy to the breast followed by an interstitial 10 Gy boost. Mean follow up of survivors: 77 months (25 to 158). Results: 5-years actuarial data (10-yr. data in brackets): Overall survival: 89.6 % (75.0 %), local control: 96.5 % (92.0 %), disease free survival: 85.5 % (77.5 %), and disease specific survival: 92.9 % (82.2 %). Local control according T-stage: TI 97.6 % (93.5 %); T2 94.2 % (89.2 %). There were no severe complications, except 1 patient with periostitis and neuralgia. The cosmetic results are very satisfactory. C o n c l u s i o n : The use of a HDR source in boosting the primary tumour site after external beam radiotherapy with a dose of 10 Gy in I fraction is a safe procedure. Our 5-years local relapse (T1 and T2) rate of 3.5 % (10-yr.: 8.0 %) and survival data are very similar to those reported in literature. Therefore we will continue with the described prospective approach.
HDR-Brachytherupy Boost for TI/T2-Breast Cancer-First Results ofu Longtcnn Follow up E.Biber, A.Resch, G. Laagbauer, T.Klcin, C. Fcllner. W. Scitz, R. Pttter University DeparUuent of Radiotherapy and Radiobiology, Vienna
888 patients with breast cancer TIll'2 N0/NI were treated with breast conserving surgery and radiotherapy (EBT and BT) between 1983 and 1992. 421 patients have been reinvestigated in a recent study with the aim to evaluate the influence of treatment on outcome and cosmetic results. 251 pts. underwent quadrantectomy, 165 tmnorectomy all with axilladissection. All pts. received EBT combined with interstitial brachytherapy (IBT).Total dose of EBT was mean 50 Gy (45 to 60 Gy) at the ICRU-point (Cobalt-60 n=219,6 MeV n=202). For HDP,BT with Ir-192 (n=288) the prescribed dose was mean I I Gy ( 10 to 12 Gy), specified to the isodose at 1 cm from the outer needle. Template technique was used in triangular configuration with mean 7 needles (4 to 10 needles) in two planes.A reevaluation was done in 50 cases resulting in the following: on the average mean central dose 17 Gy (15 to 20 Gy), treated volume 85 ccm (50 to 140ecru), TRAK 0.05 cGy at 1 m. A local recurrence ocurred in 18 of 421 cases (4,3%), 4 in the same quadrant. 343/421 pts. survived after a follow-up median 9 y. The cosmetic results were investigated with a specific questionnaire (Lent-score, QuoL) and were estimated as good (2) or excellent ( I ) (score I to 5) by 80"/, of the wo,nen, less favourable by the physicians. Fibrosis, teleangiectasia were scored according to Lent-score (fibrosisgrade 1-23%, G2-19%, G3-2.6%; Telcangieetasia G 1-8.8"/,, G2-4.4%, G3-2.6%). Poor cosmetic results were found in only 3%. The most hnponant parm'nctcrs for COSlncticoulcolne were surgical procedure, treated volu,ne (more than 100 ccm), radiation dose (> 80 Gy), inadequate application technique. In conclusion: ItDR-interstilial B'I" (Ir-192) reveals excellent local control rates and good cosmetic resulls. Dose and volume reduction of HDR-BT has been inlroduccd since 1994.